1. Physician Support for School-Located Adolescent Vaccination
A Survey of Colorado Pediatricians and Family Physicians
Emily V McCormick, MPH
Josh Durfee, MSPH
Tara Vogt, PhD
Matthew F Daley, MD, MPH
Judith Shlay, MD, MSPH

2. Financial Disclosures
The authors report no relevant financial interests regarding the work presented in this talk
This talk will not include any reference to products not licensed by the Food and Drug Administration

3. Acknowledgements Denver Public Schools Denver Public Health
Judith C. Shlay, MD, MSPH (PI)
Mette Riis, RN, MSW
Sarah Rodgers, BA
Denver Health and Hospitals
Deborah Rinehart, MA
Nicole Morgan, MHA
Simon J. Hambidge, PhD, MD
Anne Hammer, BSN, RN
U. Colorado/Children’s Hospital
Allison Kempe, MD, MPH
Jennifer Pyrzanowski, MSPH
Hai Fang, PhD, MPH
Elizabeth Campagna, MS
Karen Albright, PhD
Miriam Dickinson, PhD
Denver Public Schools
Donna Shocks, MSN, CNS, RN
Jean Lyons, BSN, RN
Scott Romero, MS
Linda Parker-Long, RN
Bridget Beatty, MPH
School paraprofessionals
School nurses
Local school administrations
Kaiser Permanente Colorado
Matthew F. Daley, MD
Monica Buhlig, MPH
Community Benefits Program
Centers for Disease Control and Prevention
Tara Vogt, PhD

4. Background – Adolescent Vaccination
A majority of vaccines are given by PCPs*
Expanded recommendations over the last decade
Annual influenza for all children
New vaccines for adolescents
Current research shows that a vast majority of vaccines are administered by primary care providers. However, this may not always be the case.
For adolescents, three new vaccines are not available and recommended that prevent five disease: tdap, hpv, and mcv.
*Szilagyi PG, Iwane MK, Schaffer S, Humiston SG, Barth R, McInerny T, et al.
Potential burden of universal influenza vaccination of young children on visits to primary care practices. Pediatrics. 2003;112:

5. Background
2010 NVAC: “As the cost of vaccines has increased, financial barriers to vaccination have emerged for health departments, providers, and the public.”
Sole reliance on PCPs to give all vaccines may not achieve high vaccination rates*
Supplementary venues such as schools have been suggested
School-located vaccination is costly and programs may need to bill insurance to be sustainable
2010 NVAC: “As the cost of vaccines has increased, financial barriers to vaccination have emerged for health departments, providers, and the public.”
Sole reliance on PCPs to give all vaccines may not achieve high vaccination rates*
Supplementary venues such as schools have been suggested
School-located vaccination is costly and programs may need to bill insurance to be sustainable
Accommodate additional office visits are not the only obstacle pcps are facing. Delivering vaccines is costly and vaccinating adolescents is complex as they are less inclined to attend well child visits.
The 2010 NVP discusses the increased costs of vaccinating for whoever provides the service. The newer adolescent vaccines are some of the most expensive in the vaccine schedule. PCPs have even considered delaying or not providing certain costly vaccines to their patients in their practice because of anticipated costs.
With these issues in mind, it is unlikely that sole reliance on PCPs to administer vaccines will achieve ideal vaccination coverage rates.
Which is why supplementary venues such as schools have been suggested to supplement the services of PCPs. Safely providing vaccines at school is just as costly and in order to be financially viable, school-located vaccination programs may need to bill for services provided.
*Cawley J, Hull HF, Rousculp MD. Strategies for implementing school-located influenza vaccination of children: a systematic
literature review. J Sch Health. 2010;80:

6. School-located Vaccination (SLV)
Schools have given influenza vaccination
School-located adolescent vaccination has not been widely used
Hepatitis B vaccine
School-located adolescent vaccination programs have not offered all vaccines or held multiple clinics
Prior studies suggest that physicians generally support SLV
It is possible that physicians are less likely to support SLV for their privately insured patients
There is a good reason that so much research is being done to test school-located vaccination delivery for adoelscents. SLV for influenza vaccination has been successful. However, slv programs have not targetted adolescents offering all vaccines in multiple visits.
Prior surveys have generally asked physicians about their support for slv, but never within a setting of an operational SLV program or specifically for their patients. Surveys have not asked about physician support by vaccination type or by insurance status of their patients.
Because of the high cost of vaccines and prospect of reimbursement, it is possible that physicians are less likely to support SLV for their privately insured patients.

7. Objectives The objectives of this survey were to:
Characterize physician attitudes regarding school- located vaccination
Compare physician support for school-located vaccination between influenza only and adolescent vaccination for their patients
Compare physician support for school-located vaccination by insurance status of their patients
With all of this in mind,
The objectives of this survey were to characterize physician attitudes regarding SLV for their patients, compare physicians support for SLV between adolescent and influenza vaccination, and compare physician support for slv by insurance status.

8. Methods – Survey instrument
20 item survey (3 pages)
Support for school-located vaccination (5 point Likert)
By insurance status
By vaccine type
Physician attitudes
Vaccination practices
Demographics and practice characteristics
Pilot tested (n=30)
Our survey, shown hear, measured support for SLV by vaccine type and insurance status, physician attitudes, and a variety of demographic and practice characteristics.

9. Methods – Survey administration
Dillman tailored design method
Pre-letter and 4 mailings
$5 incentive
Survey period: July-September 2010 (ten weeks)
Survey setting: Colorado
Sample population: American Academy of Pediatrics and American Academy of Family Physicians master file
All 669 eligible pediatricians (AAP)
Random sample of 668 family physicians (AAFP)
The survey was sent out using the Dillman tailored design methods in the summer of We sampled from AAP and AAFP masterfiles and surveyed all eligible pediatricians (669) and a random sample of 668 family physicians.

10. Analytic Plan Colinearity & Goodness of Fit tests Summary statistics
Multivariate logistic regression models using purposeful selection method
Support for school-located influenza vaccination for privately insured patients
Support for school-located adolescent vaccination for privately insured patients
Colinearity & Goodness of Fit tests
Variance inflation factor
For our analysis, we used summary stats and multivariate logistic regression to describe physician support.

11. Results

12. 584 Included in the study population for analysis
Total Sample Population 1337 Colorado Pediatricians and Family Physicians
Ineligible:
297 Do not provide primary care
64 In residency
33 Undeliverable
943 Eligible Physicians
584 Included in the study population for analysis
(Response rate = 62%)

13. Physician attitudes regarding school-located vaccination clinics (SLVC)
77%
51%
Over 80% of Physicians agreed that slv would increase vaccination rates showing that they believe slv works.
But a majority of physicians felt that if their patients received vaccines at SLVCs, their practice would have difficulty ordering vaccines and could suffer negative financial impact (51%), either from wasted vaccine or patients not attending well child visits.
77%
82%

14. Physician attitudes regarding school-located vaccination clinics (SLVC)
34%
35%
Most Physicians believed that SLV was safe not putting their patients at risk for over vaccination or adminstration errors.
And most Physicians didn’t believe that they would be relinquishing responsibility for their patients by supporting school located vaccination.
39%
71%

15. Physician Support by Vaccine Type and Insurance

16. Physician Support by Percentage of Adolescents in Practice

17. Factors associated with physician support for school-located vaccination
Variable
Adjusted OR
Ratio
95% CI
Positive Association
SLVC are easier and more convenient for patients
2.8
(1.2,6.5)
SLVC will increase vaccination rates in my practice
4.6
(2.1,10.1)
Negative Association
Supporting SLVC is relinquishing responsibility for patients
0.3
(0.3,0.5)
SLVC would have a negative financial impact on my practice
0.4
(0.2,0.6)
Difficulty projecting vaccine amounts to order because patients receive vaccine at SLVC
0.5
(0.3,1.0)
SLVC puts patients at risk for over-vaccination
(0.3,0.7)

18. Additional Findings 76% of physicians participate in Medicaid
49% would not provide their Medicaid number for billing for adolescent SLV
43% would not provide their Medicaid number for billing for influenza SLV
58% of physicians participate in VFC
Associated with physician support
66% of physician participate in the state registry

19. Limitations
Sample limited to physicians - did not include nurses, allied health professionals or administrators
Potential response bias or recall bias
Respondents may be stronger advocates of vaccination than non-respondents
The response rate for this study is robust for a physician survey
Our survey respondents were more likely to be MDs in a private practice

20. Conclusions
Physicians generally support school-located vaccination but have concerns
Their patients
Impact on their practice
Efforts to understand and address physician concerns may increase participation in school-located vaccination in the future
Accurate records
Bill for vaccination services
Physician participation in school-located vaccination efforts is imperative to create a sustainable model

21. Questions ?